The awakened person sits on the top of a hundred-foot pole;
She has entered the way but is not yet genuine.
She must take a step from the top of the pole,
And worlds in the ten directions will be her complete body.

– Zen koan

To be alive: not just the carcass
But the spark.
That’s crudely put, but…
If we’re not supposed to dance,
Why all this music?

– “To Be Alive,” by Gregory Orr

 

I am an internal medicine doctor. In that capacity, I go to distant places, meet interesting people, and eat weird food. In these journeys, I’ve noticed how technology connects us, often awkwardly, with each other. I will describe my experiences of being in these places, and you can remember that the shiny expensive brick in your pocket means that you are there, too. Through similar devices, people in distant and unfamiliar places know you. People, connected by electrons, are learning from each other about what we think of being human.

We are becoming very much more connected and as far as I can tell there is no going back. A price is being paid in the loss of pieces of our culture which do not fit a connected world. It is disorienting, dangerous, uncomfortable, and amazing.

This is what it’s like to wake up in the three places I’ve been able to serve as a doctor.

 

South Sudan:

In this new and still very unstable country, I have visited the town of Old Fangak three times. I work there with Dr. Jill Seaman, who has been battling some of the meanest infectious diseases for decades. South Sudan became independent from Sudan, the country to the north, after decades of civil war. Although there has been some peace it hasn’t lasted and civil war, primarily between two dominant tribes, has stopped people from growing food, having a consistent education, or achieving economic progress. Old Fangak is a previously very small town on a seasonal marsh by the Zaraf river, named after the giraffes who used to live there. I reach it by taking three planes to get to the capital city, then a small transport plane to a dirt landing strip, and then a small boat to the hospital complex.

thumbsup

South Sudanese woman with her baby and young son, living on the hospital complex grounds.

In the morning I wake up in my tent, surrounded by quiet, doves, and ibis. The sun is rising and it’s still cool. It has been quiet since 3 a.m., when the church groups who gathered for an official governor’s visit stopped rehearsing their huge song and dance routines. I also notice that the noise of the generator is gone, which means that the malnourished baby with pneumonia has lost access to oxygen and died. This flavors the beautiful morning with sadness. I make breakfast in a mud hut over a kerosene stove. Outside, women carry water in 5-gallon plastic buckets on their heads, and men herd errant cows along the river bank. I take the stuff from my tent and stow it away. With no school or employment, young men and boys are everywhere. They steal things that are left out, fight each other, and tease smaller or sicker kids. They stole my iPad which I didn’t really need, especially since I had just sat on it and broken the screen. Sounds of the day include motor boats on the river and small planes delivering food, supplies, and people involved in relief work. The generator at the  Doctors Without Borders compound starts up, powering the WiFi along with refrigerators and freezers that hold medicine, food, and vaccines. I walk to the hospital complex and find that another healthy baby has been delivered. At hospital rounds, I see people with pneumonia, tropical diseases, HIV, snakebites, and diarrhea, then I go to clinic where people line up for anything from malaria to arthritis to advanced cancer. Though there is no phone signal, many people have cell phones because they come loaded with music. People who own only one shirt might have a cell phone and a set of ear buds. A few hospital staff can use an expensive satellite phone to call other places and people.

 

Haiti:

Many years ago Nancy Casey (a woman who now writes, teaches, gardens, and sells fish out of a truck in my community in Idaho) visited Haiti and ended up on the island of La Gonave, about twenty miles off the coast. She made friends of people who gardened and she networked with teachers and women’s rights activists who lived there. She supported their work with money and advice. I’ve been to La Gonave four times, to a tiny community in the mountains called Bwa Nwa. I initially went with Nancy Casey but have been returning to work with local groups in health, sanitation, gardening and, recently, animal health.

birdonawire

Tropical bird on electrical wire in the women’s ward

 

In the morning in La Gonave, I awaken to roosters, usually a signal that I can sleep for at least 2 more hours. Then donkeys bray and goats bleat. I am on a full size bed inside a prefab structure that was part of an aid shipment following the 2009 earthquake. The tarantula that was hanging out on the ceiling has taken refuge from the 70-degree cold of the morning by hiding in my shoe. (Both she and I survived, thanks for asking.) There is the rhythmic sound of a large mortar and pestle crushing either millet or coffee. There is a comfortable feeling of connectedness here, where people have known each other for generations, and the sounds carrying across the still morning tell what’s happening at the houses nearby. There are no cars, but I hear an occasional motorcycle in the distance, taking a teacher to a mostly NGO-funded school where there is internet and solar electricity. There are voices of people on cell phones to others on the island; they can buy their cell phone minutes from people in the few larger towns who have top-up cards for sale for cash. After breakfast we have an animal clinic, because animals are still a main part of commerce—goats need better nutrition, and donkeys, who are the carriers of heavy loads in this place with few trucks and poor roads, get saddle sores.

 

Tanzania:

Each June for the last three years I’ve gone to Tanzania with a group of California medical students to supervise research projects and to help instruct local medical students in basic ultrasound skills. Mwanza is the second largest city in Tanzania, but has no freeways and only a few large modern buildings. We stay in a hotel that is attached to a bar and grill.

I wake to the smell of charcoal fires and the sound of cars, trucks, and roosters, and tropical bird calls from nearby Lake Victoria. Breakfast is white bread, margarine, instant coffee, hard-boiled eggs. I take a walk up the dirt and mud road to the woman making rice donuts over a coal fire. When I get back, the van is there to take us to the hospitals. The van functions as a dala dala, a cross between a cab and a bus which most people in Mwanza use to get around. The driver is ours for the week and works about sixteen hours a day just as we do, taking us to our various locations. He is using his cell phone in the morning; he might be using it to transfer money to family members in other parts of the country or to pay his utility bills. On our way to the hospital we drive by Masai, in traditional plaid blankets with staffs, herding goats and cows next to piles of plastic garbage and open-air shops selling Chinese beds. The juxtaposition of the graceful with the ugly is a stress, much like the noise of tortured engines and car horns. Traffic jams have already started by 8 a.m., and will all but stop traffic in another hour.

fishing-boat-lake-victoria_nkome-tz

Hand made fishing boat on Lake Victoria. The fish in Lake Victoria are dying because of introduction of the Nile Perch years ago, which led to a fishing boom, but then killed off more delicate species that kept the lake clean. The overgrowth and decay of plant matter depletes the water of oxygen, forcing small fish to live on the surface; these are caught in nets, dried on the sand, and sold as crunchy snacks.

Clashes of modern with traditional ways of life are accelerating, driven partly by the fact that we can now see, hear, and talk to people almost anywhere in the world whenever we wish. And some of the time they can see and hear us. Mostly we all yearn for the same things: health, love, security, a full belly, and a meaningful life.

In my own life, I’ve been noticing the increasingly intrusive presence of connection and conversation by internet. Children can’t quite engage in face-to-face conversations because they are attempting to be fully present for someone hundreds or thousands of miles away by chat. At the dinner table I open my notebook computer to settle a question. This connection is happening and will not go away because I disapprove of it.

In South Sudan people want food, security, shelter, medical care, and cell phones, along with other things they see. Not everybody has seen a computer yet, but the rest of the world is becoming more visible. In the bigger cities people have cheap and functional cell phones. In many very rural areas people can get WiFi. But in other ways, the culture hasn’t changed and has features almost entirely incompatible with global values. Most people still measure their wealth in cows. This is a very important part of peoples’ identities, yet is becoming less practical. Cows in South Sudan carry a disease called Brucellosis, which is endemic and disabling, causing arthritis, fevers, and fatigue. Personal habits such as body cutting and scarification are frightening to westerners; constant spitting is fine in an open field but doctors don’t like it in a hospital, especially if you have TB. Tribal loyalties and warfare result in grisly abuse of vulnerable people. Traditional drumming still inspires and consoles, along with singing and dancing and an amazing tolerance for physical hardships.

La Gonave, still resource-poor, with a culture that has been disturbed and coopted for years, is more intellectually sophisticated, flexible, and welcoming. There are strong family values but also high rates of sexual assault, and subjugation of women. The dependence on international aid seems to stifle any ability to create a functional, independent economy.

In Mwanza small boys still herd goats through town, but cell phones, smart phones, laptops, and WiFi are everywhere. There is terrible poverty and virtually no government safety net for the poor. Despite a powerful evangelical Christian influence, men are often married to more than one woman, though women are prohibited from having more than one husband. Women receive less education than men and the incidence of sexual assault and domestic violence is high.

These three cultures are undergoing rapid changes just like our own; miraculous communication devices bring us all closer together. In the developing world I notice the poverty and the need, which are surely real and deserve my attention, and the individual stories of tragedy that present themselves to me and which I try to address as best I can.

And there is something else as well. Now I can also open myself to the discomfort of seeing what life in the developing world is like. This is the work we’re all doing; communication brings this noticing about. We’re at a time and place in history where we are becoming more intimately connected with people who are at once different and far away but with whom we share common hopes and dreams. This intimacy is often uncomfortable, and that is part of its reality. When I open myself to these people and these places, I step away from the hundred-foot pole and allow the world in ten directions to become my complete body.


Field Notes

What Is a Zen Koan?

“The coin lost in the river is found in the river.”

“A thousand mountains are covered with snow. Why is one peak not white?”

“What is your original face before your parents were born?”

There are sayings, dialogues, questions, parts of poems, and even stories that are called Zen koans. “Koan” is an old Chinese word that means a shared conversation.

Koans serve as a way of opening up a person’s experience of life, and reveal surprising, often beautiful aspects of reality. The Zen koan schools began a millennium ago and many koans are found in ancient collections, with titles like “The Blue Cliff Record” or “The Gateless Gate” or “The Book of Serenity.” Koans are meant to change the way you understand things in a real and irreversible way, like seeing through a door that had previously been closed.

Is it special, this particular combination of words? Are the questions of our lives koans? Koans by tradition are limited to those written down long ago, but in reality, there are infinite koans. What about your life questions, like the tough decision about what to do with work or a relationship that you keep returning to? Is that a koan? Probably not, since questions like that tend to go around and around on an endless hamster wheel of predictable thinking. A koan allows a person to approach those familiar problems and decisions from the side, or from underneath, by taking away the thoughts that make the cage.

There are many different ways of working with koans, but a simple instruction is to take a koan as a companion that points you in a new direction, and be willing to let it show you something surprising. A koan will disrupt the endless circle of thoughts–planning for disaster, complaining or blaming, or defining, predicting, and explaining. A koan can be used like a compass or an amulet or a friend.

Koans can be used in meditation, or just while walking around living your normal life, or while you try to make sense of what is difficult to make sense of, or while you feel something difficult or intense. They’re often a reliable door to insight, to a view of the nature of reality that has broad implications for what’s possible in a human life.

– Rachel Boughton, Roshi